Somatic Symptom Disorder
DSM-III In DSM-III, this disorder is called Somatization Disorder Diagnostic Criteria A'''. A history of physical symptoms of several years' duration beginning before the age of 30. '''B. Complaints of at least 14 symptoms for women and 12 for men, from the 37 symptoms listed below. To count a symptom as present the individual must report that the symptom caused him or her to take medicine (other than aspirin), alter his or her life pattern, or see a physician. The symptoms, in the judgment of the clinician, are not adequately explained by physical disorder or physical injury, and are not side effects of medication, drugs or alcohol. The clinician need not be convinced that the symptom was actually present, e.g., that the individual actually vomited throughout her entire pregnancy; report of the symptom by the individual is sufficient. * Sickly: Believes that he or she has been sickly for a good part of his or her life. * Conversion or pseudoneurological symptoms: Difficulty swallowing, loss of voice, deafness, double vision, blurred vision, blindness, fainting or loss of consciousness, memory loss, seizures or convulsions, trouble walking, paralysis or muscle weakness, urinary retention or difficulty urinating. * Gastrointestinal symptoms: Abdominal pain, nausea, vomiting spells (other than during pregnancy), bloating (gassy), intolerance (e.g., gets sick) of a variety of foods, diarrhea. * Female reproductive symptoms: Judged by the individual as occurring more frequently or severely than in most women: painful menstruation, menstrual irregularity, excessive bleeding, severe vomiting throughout pregnancy or causing hospitalization during pregnancy. * Psychosexual symptoms: For the major part of the individual's life after opportunities for sexual activity: sexual indifference, lack of pleasure during intercourse, pain during intercourse. * Pain: Pain in back, joints, extremities, genital areas (other than during intercourse); pain on urination; other pain (other than headaches). * Cardiopulmonary symptoms: Shortness of breath, palpitations, chest pain, dizziness. Differential Diagnosis Physical Disorders It is necessary to rule out physical disorders that present with vague, multiple, and confusing somatic symptoms, e.g., hyperparathyroidism, prophyria, multiple sclerosis, and systemic lupus erythematosis. The onset of multiple physical symptoms late in life is almost always due to physical disease. Schizophrenia Schizophrenia with multiple somatic delusions needs to be differentiated from the nondelusional somatic complaints of individuals with Somatization Disorder. Rarely, individuals with Somatization Disorder also have Schizophrenia, in which case both diagnoses should be noted. Depressive Disorders and Generalized Anxiety Disorder Dysthymic Disorder and Generalized Anxiety Disorder are not diagnosed in individuals who have Somatization Disorder since mild depressive and anxiety symptoms are so ubiquitous in Somatization Disorder. On the other hand, a superimposed Major Depression should be diagnosed if there is a full and persistent affective syndrome that can be clearly distinguished from the individual's usual condition. Panic Disorder In Panic Disorder there are also cardiopulmonary symptoms, but these occur only in the context of panic attacks. However, Panic Disorder may coexist with Somatization Disorder, in which case both diagnoses should be made. Conversion Disorder In Conversion Disorder one or more conversion symptoms occur in the absence of the full clinical picture of Somatization Disorder. Factitious Disorder In Factitious Disorder with Physical Symptoms the individual has voluntary control of the symptoms. DSM-IV In DSM-IV, this disorder is called Somatization Disorder Diagnostic Criteria A'''. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning. '''B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: # four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination) # two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods) # one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy) # one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting) C'''. Either (1) or (2): # after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication) # when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings '''D. The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering). Differential Diagnosis General medical condition The symptom picture encountered in Somatization Disorder is frequently nonspecific and can overlap with a multitude of general medical conditions. Three features that suggest a diagnosis of Somatization Disorder rather than a general medical condition include 1) involvement of multiple organ systems, 2) early onset and chronic course without development of physical signs or structural abnormalities, and 3) absence of laboratory abnormalities that are characteristic of the suggested general medical condition. It is still necessary to rule out general medical conditions that are characterized by vague, multiple, and confusing somatic symptoms (e.g., hyperparathyroidism, acute intermittent porphyria, multiple sclerosis, systemic lupus erythematosus). Moreover, Somatization Disorder does not protect individuals from having other independent general medical conditions. Objective findings should be evaluated without undue reliance on subjective complaints. The onset of multiple physical symptoms late in life is almost always due to a general medical condition. Schizophrenia Schizophrenia with multiple somatic delusions needs to be differentiated from the nondelusional somatic complaints of individuals with Somatization Disorder. In rare instances, individuals with Somatization Disorder also have Schizophrenia, in which case both diagnoses should be noted. Furthermore, hallucinations can occur as pseudoneurological symptoms and must be distinguished from the typical hallucinations seen in Schizophrenia. Anxiety and Mood Disorders It can be very difficult to distinguish between Anxiety Disorders and Somatization Disorder. In Panic Disorder, multiple somatic symptoms are also present, but these occur primarily during Panic Attacks. However, Panic Disorder may coexist with Somatization Disorder; when the somatic symptoms occur at times other than during Panic Attacks, both diagnoses may be made. Individuals with Generalized Anxiety Disorder may have a multitude of physical complaints associated with their generalized anxiety, but the focus of the anxiety and worry is not limited to the physical complaints. Individuals with Mood Disorders, particularly Depressive Disorders, may present with somatic complaints, most commonly headache, gastrointestinal disturbances, or unexplained pain. Individuals with Somatization Disorder have physical complaints recurrently throughout most of their lives, regardless of their current mood state, whereas physical complaints in Depressive Disorders are limited to episodes of depressed mood. Individuals with Somatization Disorder also often present with depressive complaints. If criteria are met for both Somatization Disorder and a Mood Disorder, both may be diagnosed. Other Somatoform Disorders, Sexual Dysfunctions, and Dissociative Disorders By definition, all individuals with Somatization Disorder have a history of pain symptoms, sexual symptoms, and conversion or dissociative symptoms. Therefore, if these symptoms occur exclusively during the course of Somatization Disorder, there should not be an additional diagnosis of Pain Disorder Associated With Psychological Factors, a Sexual Dysfunction, Conversion Disorder, or a Dissociative Disorder, Hypochondriasis is not be diagnosed if preoccupation with fears of having a serious illness occurs exclusively during the course of Somatization Disorder. Undifferentiated Somatoform Disorder and Somatoform Disorder Not Otherwise Specified The criteria for Somatization Disorder in this manual are slightly more restrictive than the original criteria for Briquet's syndrome. Somatoform presentations that do not meet criteria for Somatization Disorder should be classified as Undifferentiated Somatoform Disorder if the duration of the syndrome is 6 months or longer, or Somatoform Disorder Not Otherwise Specified for presentations of shorter duration. Factitious Disorder and Malingering In Factitious Disorder With Predominantly Physical Signs and Symptoms and Malingering, somatic symptoms may be intentionally produced to assume the sick role or for gain, respectively. Symptoms that are intentionally produced should not count toward a diagnosis of Somatization Disorder. However, the presence of some factitious or malingered symptoms, mixed with other nonintentional symptoms, is not uncommon. In such mixed cases, both Somatization Disorder and a Factitious Disorder or Malingering should be diagnosed. DSM-5 Diagnostic Criteria A'''. One or more somatic symptoms that are distressing or result in signified disruption of daily life. '''B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: # Disproportionate and persistent thoughts about the seriousness of one's symptoms. # Persistently high level of anxiety about health or symptoms. # Excessive time and energy devotes to these symptoms or health concerns. C'. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). ''Specify if: * '''With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain. Specify if: * Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months). Specify current severity: * Mild: Only one of the symptoms specified in Criterion B is fulfilled. * Moderate: Two or more of the symptoms specified in Criterion B are fulfilled. * Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom). Differential Diagnosis If the somatic symptoms are consistent with another mental disorder (e.g., panic disorder), and the diagnostic criteria for that disorder are fulfilled, then that mental disorder should be considered as an alternative or additional diagnosis. A separate diagnosis of somatic symptoms disorder is not made if the somatic symptoms and related thoughts, feelings, or behaviors occur only during major depressive episodes. If, as commonly occurs, the criteria for both somatic symptom disorder and another mental disorder diagnosis are fulfilled, then both should be coded, as both may require treatment. Other medical conditions The presence of somatic symptoms of unclear etiology is not in itself sufficient to make the diagnosis of somatic symptom disorder. The symptoms of many individuals with disorders like irritable bowel syndrome or fibromyalgia would not satisfy the criterion necessary to diagnose somatic symptom disorder (Criterion B). Conversely, the presence of somatic symptoms of an established medical disorder (e.g., diabetes or heart disease) does not exclude the diagnosis of somatic symptom disorder if the criteria are otherwise met. Panic disorder In panic disorder, somatic symptoms and anxiety about health tend to occur in acute episodes, whereas in somatic symptom disorder, anxiety and somatic symptoms are more persistent. Generalized anxiety disorder Individuals with generalized anxiety disorder worry about multiple events, situations, or activities, only one of which may involve their health. The main focus is not usually somatic symptoms or fear of illness as it is in somatic symptom disorder. Depressive disorders Depressive disorders are commonly accompanied by somatic symptoms. However, depressive disorders are differentiated from somatic symptom disorder by the core depressive symptoms of low (dysphoric) mood and anhedonia. Illness anxiety disorder If the individual has extensive worries about health but no or minimal somatic symptoms, it may be more appropriate to consider illness anxiety disorder. Conversion disorder (functional neurological symptom disorder) In conversion disorder, the presenting symptom is loss of function (e.g., of a limb), whereas in somatic symptom disorder, the focus is on the distress that particular symptoms cause. The features listed under Criterion B of somatic symptom disorder may be helpful in differentiating the two disorders. Delusional disorder In somatic symptom disorder, the individual's beliefs that somatic symptoms might reflect serious underlying physical illness are not held with delusional intensity. Nonetheless, the individual's beliefs concerning the somatic symptoms can be firmly held. In contrast, in delusional disorder, somatic subtype, the somatic symptom beliefs and behavior are stronger than those found in somatic symptom disorder. Body dysmorphic disorder In body dysmorphic disorder, the individual is excessively concerned about, and preoccupied by, a perceived defect in his or her physical features. In contrast, in somatic symptom disorder, the concern about somatic symptoms reflects fear of underlying illness, not of a defect in appearance. Obsessive-compulsive disorder In somatic symptom disorder, the recurrent ideas about somatic symptoms or illness are less intrusive, and individuals with this disorder do not exhibit the associated repetitive behaviors aimed at reducing anxiety that occur in obsessive-compulsive disorder.